An application to operate a Residential Care Facility for the Elderly (RCFE) was received on 12/04/2024. Component II was completed on 08/07/2025. Fire clearance was granted on 01/27/2025 for 54 (fifty four) non-ambulatory residents. During today's visit the private room numbers were updated on the approved fire clearance to match the facility sketch. Room #20, 23, and 25 are private rooms. The facility has a pending hospice waiver for 4 (four) residents. During today's visit, Component III was reviewed with the facility representatives.

The facility consists of 27 (twenty seven) total bedrooms – 24 (twenty four) shared rooms and 3 (three) private rooms. There are 5 (five) shower rooms, 2 (two) full shared bathrooms, there are shared jack-and-jill style half-baths throughout the facility and a designated staff restroom. Shared facility space includes a common tv room, game/reading room and dining area. There is currently a total of 50 (fifty) residents residing at the facility.

A tour of the facility was initiated at 10:43AM with facility representatives. LPAs inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted:

Report Continued on LIC 809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Kitchen: The facility kitchen was observed to be clean and functional, with inaccessible knives and sharp objects. The facility follows a menu and has a contracted dietician consultant. Bedrooms: There are 27 total bedrooms in the facility. 3 are private resident bedrooms and 24 are shared resident bedrooms. Various resident rooms were observed and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPAs observed various resident bathrooms, which were clean, properly supplied and had functional fixtures. LPAs observed all bathrooms to have grab bars and slip-resistant surfaces. Residents have sufficient amounts of supplies for personal hygiene. LPAs checked water temperature in various bathrooms during the visit, all measured within regulation of 105-120 degrees F. Common Areas: These included the common tv room, game/reading room, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. LPAs observed cameras throughout the common areas. Representatives indicated camera use is addressed in the pending facility's plan of operation and Admission Agreement. There is a designated telephone available for resident use. Cleaning supplies are stored in a locked cabinet. Surrounding Grounds (Outdoors): There were various shaded areas with proper furniture for outdoor use. There are no bodies of water on the premises. The fence separating the facility patio area from the parking lot had no gate, but had an open space for a gate, leaving a large opening in the fence. At this time, there are no residents with a dementia diagnosis or elopement or wandering behavioral expressions. Licensee representatives were advised that if any residents accepted for care do have behavioral expressions that might put the resident at risk with the condition of the fence, protective measures will need to be taken to protect the resident. Medication: Medication room was observed locked and contained all resident medications and medication records. First aid supplies are available in both the medication room and the staff office. Infection Control Plan and Emergency Disaster Plan: During today's visit, the LPAs reviewed the facility's infection control plan and emergency disaster plan, both of which were complete and recently updated.

Report Continued on LIC 809-C (p.3)

- Signal system meeting the requirements of Title 22, 87303(i) to be installed and functional

- Proof of all fire extinguishers serviced within the last 12-months and indicated as fully charged

- Sufficient quantity of emergency food and water

- Any necessary additional corrections addressed on the Annual visit report for the currently licensed facility

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.